O0110D3c. Treatment: Suctioning- As needed- At Discharge, Step-by-Step

Step-by-Step Coding Guide for Item Set O0110D3c: Treatment: Suctioning - As Needed - At Discharge

1. Review of Medical Records

• Objective: To identify plans for the continuation of as-needed suctioning treatments as part of the resident's discharge plan.
• Action Steps:
  • Conduct a thorough review of the resident's medical records, with a focus on discharge planning sections, physician orders, and respiratory therapy documentation.
  • Look for documentation specifying the need for as-needed suctioning post-discharge, including the method (oral, nasal, tracheal), and clinical indications.

2. Understanding Definitions

• Suctioning (As Needed/PRN): A medical procedure performed to clear the airways of secretions or blockages, executed based on the resident's immediate needs and not at scheduled intervals.
• At Discharge: Refers to treatments or interventions recommended for continuation as the resident transitions from the facility to another care setting or home care.

3. Coding Instructions

• Action Steps:
  • Code for suctioning if it is included in the discharge instructions, indicating a need for the treatment to continue on an as-needed basis beyond the facility's care.
  • Document the specifics of the PRN suctioning treatment prescribed for after discharge, including clinical indications for its use.

4. Coding Tips

• Ensure clarity in the discharge plan regarding the PRN nature of the suctioning, including specific criteria for when the procedure should be performed.
• Distinguish between PRN suctioning and any scheduled suctioning to ensure accurate coding.

5. Documentation

• Essential Elements:
  • Document the clinical justification for continuing PRN suctioning treatment, detailing the resident's condition that necessitates this care.
  • Provide comprehensive instructions for post-discharge care providers, including how to perform the suctioning, equipment needed, and signs indicating the need for the procedure.

6. Common Errors to Avoid

• Omission: Not documenting or coding for PRN suctioning as part of the discharge plan when clinically indicated.
• Lack of Specificity: Failing to provide detailed instructions for PRN suctioning post-discharge, leading to potential care gaps.

7. Practical Application

Example Scenario: A resident with a history of aspiration pneumonia requires oral suctioning to manage excess secretions, especially during and after meals. As part of the discharge planning, the care team includes oral suctioning on an as-needed basis in the resident's home care instructions. Detailed criteria for initiating suctioning include visible secretions, coughing during meals, or signs of respiratory distress.

Please note that the information provided in this guide for MDS 3.0 Item set O0110D3c was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.